Every day I experience life in the world of healthcare IT, supporting 3000 doctors, 18000 faculty, and 3 million patients. In this blog I record my experiences with infrastructure, applications, policies, management, and governance as well as muse on such topics such as reducing our carbon footprint, standardizing data in healthcare, and living life to its fullest.

Thursday, October 29, 2015

I’m back from China and have caught up on the accumulated farm work that built up in my absence. I did what I needed to do in Asia, lecturing about Meaningful Use accompanied by lasers and fog, but not fireworks.

Kathy kept everyone healthy and happy (such as the chickens and bees below) but the more physical work - chainsawing fallen trees, hauling hay, digging trenches, fixing irrigation, and cider production work falls to me.

The ash borer beetle has caused the death of ash trees through the US including those on Unity Farm. Although we do not have an active infection, the dying trees have been decaying and collapsing over the past few years. I’ve proactively taken down all ash trees near structures, but multi-ton trees still fall in the forest, sometimes getting caught up on the branches of other trees. Cutting down these mammoth stuck trees is very dangerous and that’s why they are called “widow makers”. With Kathy standing at a safe distance in case I run into trouble, I cut them down using a plunge cut technique

The farm driveway replacement project continues to progress but during the excavation several irrigation pipes were cut. It was not clear which were old pipes and which were new pipes. The person helping us with the project repaired them using a standard coupler technique. Unfortunately he connected the wrong two pipes together so the resulting configuration did not work. I excavated the existing pipes and followed them from their origin to their destination, cutting out old pipe and reconnecting the system.

During my absence, the cider fermented from a specific gravity of 1.050 to 1.000 creating 6.1% alcohol by volume. Upon returning from China, I racked all the cider into fresh sterilized fermenters for the secondary malolactic fermentation over the winter. The 2015 cider is delicious and I’ll bottle it in the Spring.

One of the major problems of traveling the Fall is missing the major part of the mushroom harvest. Kathy did a great job harvesting the Shiitake crop and selling it to farm stands/markets throughout the Boston metro west area. The only thing for me to do is move our 100 new logs to the inoculation area where we’ll drill and add spawn to them over the next month or so.

Finally, it was time to clear out the green houses and plant the last of the fall crops, including garlic. Our 16 raised beds are now filled with winter density lettuce, spinach, chard, and romaine. The hoop house and floating row covers will keep them warm during the 100 days of winter ahead.

This weekend we'll begin the winter prep of all our machinery - changing oil, adding gas treatments, and washing off the accumulated dirt of summer in preparation for the snow that is soon to fall

2. The concept of the Complete EHR was eliminated in the 2014 Edition Release 2 final rule. Everything in the 2015 Certification rule is conditional based on the functionality that a module supports. The CMS Meaningful Use rule requires certified technology to support each element of that rule, but customers are encouraged to select modules/vendors/applications however they wish.

3. There are standards included in the 2015 Certification rule that are not ready for prime time, such as Data Segmentation for Privacy (DS4P). However, there are no corresponding Meaningful Use attestation criteria for these standards, so vendors are unlikely to implement them. I believe the 2015 Certification Rule should be limited to Meaningful Use certification without optionality in the interest of providing a clear path to the industry. The ONC Standards Advisory could have enumerated the potential standards suggested for non-Meaningful Use related requirements. Luckily, ONC has prepared a presentation which illustrates the sections of the 2015 Certification Rule that can be ignored by vendors seeking to limit their development effort to Meaningful Use support.

Slide 35 contains a final rule table. The last column to the right enumerates certification criteria and accompanying standards outside of Meaningful Use. The first column is always applicable for products getting certified and the second column is conditionally applicable depending on what criteria are in scope for certification.

If you want to read the actual 560 page rule, you can save a great deal time by just reading about 50 pages as follows

The standards required by the rule are described between 170.202 Transport standards and 170.299 Incorporation by reference.

The certification requirements are described in section labeled Regulation Text.

There are really only three new substantive requirements applicable to Meaningful Use that are non-public health: implantable device list, patient generated health data capture, and the Application Program Interface functionalities. Otherwise, all the other “new” criteria are public health specific to give more Meaningful Use flexibility. As noted above, slide 35 in the presentation is key. Some of the “revisions” are really minimal in comparison to 2014 edition despite being marked that way.

Assessing the vendor burden of implementing the 2015 Certification rule is heavily dependent on the number of functions certified. There are even optional choices for some criteria. For example, in the View/Download/Transmit criteria there are two standards referenced for web content accessibility guidelines, Level A and Level AA. The baseline requirement is Level A, which effectively makes Level AA “optional”. However, vendor implementation details will be represented on ONC's updated "open data" Certified Health Product List so if a developer wanted to differentiate themselves on web content accessibility they would be able to do so and such effort would be publicly accessible.

Overall there are more criteria to support public health for Meaningful Use than providers need to actually use to meet Meaningful Use, so there is flexibility for public health reporting. Developers do not need to support all the public health certification criteria.

I hope this analysis helps you focus since the powerpoint plus reading about 50 pages is all you have to do to understand the 560 page rule.

My only editorial comment - in the future, I believe the private sector will innovate in ways that regulation cannot foresee. There is a time for regulation to catalyze change and a time for regulation to be reduced to enable innovation. I believe that we are entering a time for reduction of regulation. My term limit in the Obama administration requires my service in the federal advisory committees to end in January 2016. I will watch with great interest as the Obama administration ends and a new administration works to find a balance between regulation and private sector innovation.

Thursday, October 22, 2015

October is the best time of year to travel in Shanghai and Beijing. The temperature is typically between 60-75F and there is little rain. Air quality is reasonable and transportation systems are at their most efficient.

In my role as Harvard professor, I spend a few days a year in Asia, Europe, and the Middle East helping define technology and policy for improving healthcare quality, safety and efficiency. My Fall travels to China always occur in the middle of harvest season, which can be challenging for the farm.

During my travels this week, we had our first hard frost - 8 hours of temperatures between 26-29F. That was enough to kill the remaining annuals - shiso (Japanese basil), morning glories, tomatoes and peppers. My wife and a helper composted all the affected plants. Here’s a view of the wilted tomatoes.

All the leaves have turned and the farm is past the peak of color.

The Shitake mushrooms are at the peak of their fruiting and Kathy is gathering basketfuls every day. We have 100 new oak logs to inoculate when I return from China.

It’s the perfect time to plant garlic. We have 6 raised beds devoted to garlic and Kathy is getting 12 varieties into the ground before the soil hardens.

The farm hand who covers for me while I travel used our commercial mower to do the last cutting of the year through our orchards, pastures, and meadows.

He’ll also use a brush cutter to clear the last areas of wildflowers in the bee areas now that they are at the of their growing season.

The pawpaw trees we planted as part of our permaculture are beginning to lose their leaves and the peak of fall color is passing.

The duck pond is filling with falling leaves and needed a cleaning.

All the animals are enjoying the cooler weather, but miss the routine of the extra attention I give them while I’m there, cleaning, special feedings, and walks.

Kathy has done the last of the bee work for the season, since it is now too cold to open the hives.

I started the fermentation of our cider batches before my departure and Kathy has been watching them to ensure they are vigorous but not too vigorous. I’ll rack the ciders and inoculate them with malolactic bacteria for their secondary fermentation when I return.

The paving project continues and we’ve excited to see the 25 year old asphalt replaced with simple pavers that we can easily replace/repair given the wear and tear of our farm equipment and activities.

Kathy has done a remarkable job keeping everything running during my absence. I look forward to my return on Saturday when I can catchup with the projects in progress and re-engage with the rhythm of the farm.

Wednesday, October 21, 2015

I’ve been asked to summarize the 752 page CMS Meaningful Use Final Rule.

Although it is a final rule, it has a 60 day comment period, so there is still is an opportunity to modify some of the criteria. Between the Notice of Proposed Rulemaking and the publication of the CMS Final Rule, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) passed to include sunsetting the Meaningful Use payment adjustment for professionals at the end of 2018. Also, MACRA requires the establishment of a Merit-Based Incentive Payment System (MIPS) which would incorporate Meaningful Use. The comment period will be used in an attempt to align the Meaningful Use program and the MIPS program.

The CMS Final Rule contains revisions to Meaningful Use Stage 2 such as reducing the reporting period for 2015 to 90 days and changing the patient/family engagement thresholds from 5% of patients to 1 (a single) patient.

The Stage 2 changes followed the recommendations of several professional societies. Hopefully more clinicians and hospitals will now be able to cross the Meaningful Use Stage 2 finish line.

Stage 3 is more controversial and I will focus on that.

Eligible Professionals (EPs) and Hospitals have 8 goals with optional participation in 2017 and required participation in 2018 to gain stimulus and avoid penalties. The rule was released in October 2015 and since it is optional for 2017, vendors have only 1 year to make software changes and get certified. That could be very difficult, especially for the application program interface (API) requirements described below. Here are the goals:

1. Protect Electronic Health Information - a security assessment must be done and a mitigation plan followed to reduce risks of privacy breach. Appropriate encryption of data must be included in the plan. This applies equally to EPs and hospitals.

2. Electronic Prescribing - For EPs, electronic prescribing must be done for 60% of electronically prescribe-able medications. Electronic prescribing of controlled substances is not required but can be counted. For hospitals, electronic prescribing must be done for 25% of electronically prescribe-able discharge medications.

3 Clinical Decision Support - five clinical decision support interventions related to four or more clinical quality measures as well as support for drug/drug and drug/allergy checking must be implemented. This applies equally to EPs and hospitals.

4. Computerized Provider Order Entry (CPOE) - 60% of labs, radiology, and medication orders must be done electronically. This applies equally to EPs and hospitals.

5. Patient Electronic Access - 80% of patients must be given access to View/Download/Transmit AND Application Program Interface (API) capabilities. 35% of patients must receive tailored educational resources electronically.

I suspect the API requirement may be among the most controversial aspects of the final rule. I’m a strong supporter of the use of APIs as a means to enhance interoperability, such as we’ve proposed with the Argonaut Project . However, at the moment, there are few patient facing applications that use APIs. Maybe in the future, the problem of multiple PHRs will be addressed by moving patients from portals to apps that consolidate data from multiple EHRs i.e. the patient’s PCP, specialists, urgent care clinicians, and hospital care team.

6. Coordination of Care through Patient Engagement - 10% of patients must access their record via a portal or application program interface. 25% of patients must receive or send a secure email. Information from non-clinical settings must be received for 5% of patients, which includes patient-generated data (weight/blood pressure/glucometer readings or Fitbit-like devices) or data from providers in non-clinical settings such as home health or physical therapists or behavior health. This applies equally to EPs and hospitals.

I wonder if regulation is the best approach to accelerate the move to consumer-facing mobile apps and APIs for downloading of EHR data and uploading of patient generated data. Meaningful Use Stage 2 attempted to use regulation to accelerate patient downloading/transmission of data. There were few places to transmit consumer data and few compelling reasons for consumers to do it, so few tried. Meaningful Use Stage 2 was revised to move the 5% view/download/transmit requirement to just one patient. Regulation alone cannot change consumer behavior since APIs are not so much a technology but a market ecosystem to support the technology. One of the lessons of Direct is that such challenges are profound and cannot be created overnight based on federal regulation.

A better driver would be a payment model such as risk-based pay for outcomes approaches which incentivize patients and providers to collaboratively share data using novel applications. I would advocate removing the API requirement from Meaningful use Stage 3 and moving it to the merit-based incentive programs (MIPS), enabling the marketplace to evolve innovative technologies after there is increased consumer and provider demand.

7. Health Information Exchange - Transition of care summaries must be sent for 50% of all encounters. Transition of care summaries must be incorporated for 40% of patients. Transition of care summaries must be reconciled as structured data (problems/medications/allergies) for 80% of patients.

Unlike MU Stage 2, providers will now have to receive as well as send data. Reconciling problems for 80% of patients will be quite challenging because of the different ways that providers maintain problem lists, which, unlike meds and allergies, has less to do with coding objective findings and more to do with documentation conventions and individual habits.

8. Public Health and Clinical Data Registry Reporting - immunization submission, syndromic surveillance (urgent care only for EPs), electronic case reporting, cancer registries or surveys, data registry reporting, reportable lab are required for EPs and Hospitals. There will be exceptions offered for areas in which public health entities cannot receive these transmissions.

My general opinion of the rule is that
*The Stage 2 revisions that enable a 90 day reporting period and reduce some of the thresholds are good.
*The Stage 3 API requirement and patient generated healthcare data are better done in merit-based payment approaches rather than Meaningful Use regulation
*The collective burden of all the workflow changes required by three stages of Meaningful Use regulations will make it hard for clinicians to get through their day and spend time on direct patient care
*The public health reporting requirements will be hard to achieve in many locations due to the heterogeneity of local public health capabilities
*Many EPs and hospitals would welcome the end of Meaningful Use in favor of merit-based payment because at this point it is more effective and efficient for them to focus on achieving better outcomes for value-based care than being told exactly how they should get there.

Thursday, October 15, 2015

I’m in China for the next week with limited access to social media sites, so a few blog posts will accumulate on my laptop until I return.

Here’s the farm update.

Mid-October is a remarkable time of year in New England. Mornings are crisp and afternoons are warm. The work is easy because clothing layers can come on and off to arrive at perfect comfort.

As is typical on the farm, weekends and nights are buzzing with activity. From dawn to nightfall, there is harvesting, hauling, and storing to be done. This week, our cider recipe was

40% Honeycrisp
20$ Macoun
20% McIntosh
20% Gala

Our tanks of cider are fermenting at 55 degrees for two weeks then a secondary malolactic fermentation will last all winter. We’ll bottle in the Spring. Here’s what cider pressing looks like, aided by the buff geese, which are always eager to help.

The Shitake mushrooms are bursting from their logs and we’re selling to local farm stands and markets. We’ve exhausted our farm supply of oak logs, so we’re buying loads of oak from nearby arborists. A perfect load of 100 logs, each 4 feet long and 6 inches in diameter arrived on Wednesday night. Kathy and I will be inoculating them until it gets too cold for us to do the drilling, spawn inserting and waxing into over 50 holes per log that is needed to prepare a Shitake log

We’re at the peak of Fall color right now with oaks glowing yellow and maples glowing red. Now that I’m familiar with all the technologies needed to build tree houses I’m able to take an idea and turn it into a structure in a few hours. About a quarter of our farm is true wilderness - filled with deer, turkeys, pheasants, foxes, and raccoons. I explore it on deer trails and have purposely not developed the area. I found a 100 year old red maple that shared a glen with a stately pine tree. I imagined a 14 foot high observation platform in the red maple intertwined with the boughs of the pine. Using treehouse attachment bolts with very minimal impact on the maple, there’s the finished result. I call the area Momiji Matsu - Japanese for Red Maple and Pine. I have one more observation platform to build this year. A 4 foot diameter pine overlooking the railroad tracks will soon have a 16 foot high platform to watch the slow freight trains pass the farm. I’ll call that platform, which will connect to a confluence of 4 large pine trunks, the Crow’s Nest.

Fall color takes many forms - the last wildflowers of the season are blooming and the bee yard is splashed with purple asters and daisies.

The alpacas and llama enjoy a breakfast of alfalfa mixed with molasses. Their coats have fully regrown after their May sheering and they are ready for winter. Alpacas love cold but not snow. My work is keeping their paddocks clear of snow with tractor/snowblower.

The hoop hose has one final burst of vegetables for us to harvest. Although the temperatures at night can be near freezing, the hoop house is like a tropical garden during most of the day. Here’s a view of the lush lettuces, chard, and spinach awaiting harvest. In the chard, a leopard frog keeps the insect population under control. Running a fully organic hoop house is probably the only way you can attract leopard frogs to your vegetable beds.

Imagine the contrast I’m feeling this week - from solitary platforms in the maples to the bustle of Shanghai. Although farming is a passion, helping improve the healthcare of 1.3 billion people in China is my mission this week.

Thursday, October 8, 2015

We had 4 inches of rain this week, bringing a welcome end to the drought of the past 30 days. Over the past few years we’ve worked hard to regrade the landscape around the farm and ensure water drains away from buildings. Not a drop entered any structure.

The nights are turning cold and we’ve restarted the fireplaces at night. I welcome the opportunity to spend evenings around a cheery fire.

We’re splitting the last of the 2015 harvested wood - ash and cedar can be burned without aging, but all other woods will be cured for a year.

This week we replaced the barn doors that were over 20 years and starting to decay. Our first clue was the one foot hole the geese poked in the rotting wood.

I put the finishing touches on the zip line this week, adding a backup stop block, just in case the brake fails. I also built a landing platform that allows the rider to stand, step, and unclip before climbing back to ground.

We picked apples - everything in the orchard that was over 15 Brix. My favorite eating apples are Empire and Macoun, which we’ve set aside. We’re making craft cider from the Ben Davis, McIntosh, Cortland, Pink Lady, and other varieties. Some have have asked if we have help with the harvest. Here’s a photo of our 4 picking staff, who really enjoy eating apples and pears during the process.

Cool Fall nights are great for growing lettuce. Here’s a photo of the lettuce harvesting crew

Our smallest rooster, Tyrion (Bantam Cochin), has paired with our largest female, Midnight
(Jersey Giant). We look forward to seeing the offspring of that pair!

Our last major project of Spring is replacing our aging driveway before the snow falls. We’re digging down 9 inches, adding course rock drainage and using pavers instead of asphalt. Kathy designed a compass rose to sit at the center drive and the serve as a directional guide for all our farm locations.

I do not sleep much, which works out well on farm that requires me to check on the animals in the middle of the night. At 2am last night, the geese were particularly upset. In the morning, I found out why - a raccoon had been pestering them but could not enter their secure pen. As soon as we let the geese out in the morning they chased the raccoon back to its home in the hollow of a tree - here’s what a raccoon looks like after it’s been chased by angry geese.

Tuesday, October 6, 2015

Steve Posnack from ONC declared today IT Bonanza Day. The Interoperability Roadmap, CMS Meaningful Use Final Rules with a Comment Period (Stage 2 and 3) as well as the ONC 2015 Certification Rule were published today.

It remains to be seen how the comment period on the EHR Incentive Programs final rule will be used to align the Meaningful Use program with the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) effort. It would not surprise me that the CMS final rules are not really final.

There will be one Meaningful Use rule that will cover 2016 to 2018 both modifications (to Stage 2) and Stage 3.

The final rules are not substantially different than the proposed rules, but the thresholds have been reduced. Given that existing certified EHRs were created to support the previous Stage 2 thresholds, I'm guessing vendors will have to modify code to support the changes.

2017 will still be an optional Stage 3 reporting year. 2015 will be a 90 day reporting period for everyone.

Quality measures have not changed, but the industry will have to support other initiatives in merit-based performance that have requirements.

In the upcoming days, I will review the certification criteria in detail. Immature standards such as HPD for provider directory query have been removed. Others such as DS4P for data segmentation are included but are not required.

CMS and ONC have incorporated many of the changes requested by professional organizations and expert commentators, which is a good thing.

The afternoon was filled with a review of the Interoperability Roadmap by Erica Galvez and Steve Posnack. The roadmap is divided into three themes - drivers, policy & technical components, and outcomes.

A very good discussion and our last in person meeting for 2015.

Not only ONC is working on these issues, but also the private sector is stepping up its efforts. Last week the CEOs of every major EHR company in the country met in Salt Lake City, convened by KLAS to have a two day discussion with leading provider organizations and informatics experts. The end result - a consensus on the objective measures we can use to quantify interoperability. The message to Congress and to all stakeholders outside of government is that an independent entity will be publishing transparent quantified measures of health information exchange that can serve as the basis for understanding our current position and trajectory. We’ll understand gaps, barriers, and next steps. Every vendor CEO agreed that interoperability is a public good that should be embraced by all. You’ll hear more about this meeting soon.

Friday, October 2, 2015

Many in the press have asked me about the first few days of ICD10. The answer for my institutions, like many, is that other than a few small refinements, the impact has been unnoticeable.

We trained 850 ambulatory clinicians in comprehensive ICD10 code entry and all are entering electronic billing tickets using the new vocabulary.

All our provider order entry systems have Medicare Advanced Beneficiary Notification logic using ICD10 and our clinicians are using it.

Every financial system is able to process both ICD9 and ICD10 to support patients who were admitted on 9/30 and discharged on 10/1

We added some subtle post go live modifications to decision support logic, ensuring all ICD10 codes are supported and we modified some very esoteric charge entry items directly related to the transition day.

Our ICD10 go live scorecard listed only 5 minor issues across all sites which our local teams were able to review and quickly close.

Congratulations and thanks to all involved in this extremely smooth go live. Our next steps will be monitoring the coding of the initial inpatient cases and payer submissions along with watching reimbursements over the next 60 days. We’ve done all we can to prepare. Let’s hope the ecosystem around us can process our transactions with the same resilience.

Thursday, October 1, 2015

When we first moved to Unity Farm, I became a timber expert - managing 15 acres of oak, maple, cedar, birch, poplar, and hickory. I learned about the character of each of the trees, their wood, and their ecosystems.

By building the Unity Farm tree house, I became an expert in tree house support systems, ensuring structural stability while avoiding harm to the tree.

Last weekend, building a 300 foot zip line, I’ve learned how to create transportation systems between trees. There were many lessons learned.

First, everything you’ve seen in movies about zip lines is false. Batman just shoots a cable into a wall and then glides down the 45 degree slope. Not possible.

Zip lines are typically constructed with a 6% slope. An 8% slope would be very exhilarating. A 10% slope would be terrifying. Anything greater would be deadly.

First, I used a sight level to assess the change in elevation of the topography of the Unity farm upland forest.

I chose two trees, 300 feet apart, that were 2.5 feet in diameter with an appropriate elevation difference.

I then applied a protective 12 inch collar of 2x4s around the trees such that the zip line would be 7 feet high at the termination. I created a 6% rise over 300 feet to the launching tree. Can you find the straight cable going through the forest in the picture below?

Using a cable grip and come along tool, I pulled 5/16’s aircraft cable between the two trees and attached it to the trees by using a separate piece of cable around the 2x4 collar and turnbuckles. Here's a photo of the tree at the end of the run

I ensured the cable was not piano wire tight, but had about a 2% sag.

I created a 30 foot bungee brake set at 60 feet from the termination.

Donning a climbing helmet, harness, carabiners, and climbing sling, I attached myself to a trolley pulley on the line. Just in case my planning failed and I needed medical attention, I put my cell phone on my harness and launched.

I survived the experience, going from tree to tree at about 30 mph. The brake worked perfectly and I stopped about 15 feet from the end point.

There is a bit more work to do, creating a landing platform that makes it easy to unclip the harness from the trolley, but I’m impressed by the ease of creating and managing zip lines as long as you have the right equipment and tools.

Last weekend I did another refractometer check of the apples and the Macoun, Gala, McIntosh and Northern Spy are all at 15% sugar. We’ll harvest them this weekend.

For our first cider batch of 2015 we chose a two parts Honey Crisp, one part Gala, and one part McIntosh. The apples are in our walk in refrigerator, ready for crushing this weekend.

A local resident was recently asked to give up his rooster because neighbors complained about crowing at all times of day and night. At Unity Farm, we have crowing, barking, honking, quacking, and buckwheating (Guineas) 24 hours a day, so extra crowing would not even be noticeable.

The rooster is a bantam cochin - small chicken with a very ornamental look. His size may be small but his personality looms large over the barnyard. In homage to Game of Thrones, we named him Tyrion. Here’s a photo

I travel to China on October 15 for a week, so the first part of the month will be finishing all the harvesting and cider making before I leave. This will be my last year of traveling in October. Planting can be done at many times during the year, but harvest is always in October. As my wife says, living things must take precedence